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June 2001

Bipolar Disorder Appears More Severe in Children Than in Most Adults
Children as young as 7 years old can develop bipolar disorder, and the illness in young bipolar children resembles the most severe form of bipolar disorder in adults, according to a study from researchers at Washington University School of Medicine in St. Louis, Missouri. The findings were presented at the Fourth International Conference on Bipolar Disorder in Pittsburgh, Pennsylvania.
"We want to distinguish between children with bipolar disorder and ADHD because many parents, teachers and health care providers might confuse the overlapping symptoms of the two problems and think that these are just hyperactive kids," said Barbara Geller, MD, the study's principal investigator.
Geller and colleagues are studying 268 children, 93 with bipolar disorder, 81 who have attention deficit hyperactivity disorder (ADHD), and another 94 healthy children from the community. The average age of the bipolar children involved in this study was just over 10. More than half had not yet reached puberty and 43% were between the ages of 7 and 10 years old. Almost a quarter of the bipolar study participants were seriously suicidal.
"Typically, adults with bipolar disorder have episodes of either mania or depression that last a few months and have relatively normal functioning between episodes," said Geller, who is a professor of child psychiatry at Washington University School of Medicine in St. Louis, Missouri. "But in manic children we have found a more severe, chronic course of illness. Many children will be both manic and depressed at the same time, will often stay ill for years without intervening well periods, and will frequently have multiple daily cycles of highs and lows. These findings are counterintuitive to the common notion that children would be less ill than their adult counterparts."
This work was developed to diagnose bipolar disorder in children as young as 7 or 8 years old, something that rarely has been attempted. Whereas physicians and relatives might suspect bipolar disorder in an adult with behavioral problems such as "maxing out" credit cards, getting married four or more times, or continually starting new, unrealistic business ventures; Geller's group needed to establish how these behaviors would appear in children.
"A bipolar adult with symptoms of grandiosity might call the President or the Governor to tell him how to run things," Geller said. "In this study, we have investigated children who have repeatedly called the principal or other officials at school to tell them to fire a teacher or do something else to make the school run more effectively in the eyes of that child." These children were not just playing teacher after school but were acting as if they were in charge of the principal's office.
Geller's group has now validated the mania diagnosis in these young children by showing that the symptoms are stable at follow-up over a one-year period. This helps dispel the notion that manic children were just children with ADHD who were having a bad day.
The study participants were evaluated diagnostically in the research unit, but were treated by their own practitioners in the community. Only about 50% of the bipolar children in the study were receiving medications that are prescribed to control mood swings in bipolar adults, such as lithium, neuroleptics, or anticonvulsants.
Geller believes this low use of anti-manic medications may be because gatekeeper physicians are not yet aware that children can have manic-depressive illness.
Only about one-third of these children had recovered from their mania at the end of one year. Geller plans to continue following these children over time to see if their chronic, rapid cycling illness continues or if they will develop the episodic pattern with relatively well periods that is seen most commonly in adults. Her group also is conducting molecular genetic and neuroimaging studies to learn whether the genetic factors involved in the disorder are similar for children and adults and whether the brains of children with bipolar disorder differ from the brains of normal children. 
This research was supported by grants from the National Institutes of Health.

Is Nicotine an Antidepressant? 
New research shows that people who have a history of clinical depression are six times more likely to become depressed again if they quit smoking, compared to those who continue to smoke, HealthScoutNews reported June 19. Dr. Alexander Glassman, chief of clinical psychopharmacology at Columbia University's New York State Psychiatric Institute, conducted a six-month study of smokers with a history of major depression who were not taking an antidepressant. Participants were enrolled in a smoking-cessation program, with some smokers given either the antidepressant Zoloft or a placebo.
Twenty-one days after taking the drug or placebo, smokers selected a quit-smoking date.
"We followed everybody after they finished the Zoloft and were off all medication, and we followed both the successes and the failures," said Glassman. "The Zoloft, by the way, did not help them with the smoking cessation."
According to Glassman, of the successful quitters, "more than 30 percent developed a new episode of clinical depression." He added, "That's a six-fold increase in the risk," compared to quitters not prone to depression.
Glassman said that the study shows that "nicotine acts like an antidepressant. That could mean a whole new arena for new antidepressant drugs. It's quite possible you could make derivatives of nicotine that wouldn't have the medical complications of nicotine but could prove very useful in the treatment of clinical depression."
"There seems to be some truth in the notion that some of the people who smoke are self-medicating with nicotine to avoid clinical depression," continued Glassman. "I think the logical step for those trying to quit -- and I emphasize this has not been proven to be correct -- is that if you used an antidepressant like Zyban to stop smoking, don't stop the drug after you've successfully quit."
The findings are published in the June 16 issue of The Lancet.

Dietary Changes Improve Autistic Symptoms in Some Patients
Elimination of dairy, gluten and other food components dramatically improves the symptoms of children and adults with autism, according to preliminary results presented Thursday at the 12th International Conference on Autism, held at Durham University in the UK.
Previous studies suggest that more than 50% of autistic children show significant improvements when dairy products and gluten are eliminated from their diet, explained Dr. Ted Kniker from the San Antonio Autistic Treatment Center in Texas. "The theory is that poorly-degraded food proteins leak from the gut into the blood, and peptides with opioid activity adversely affect brain function," he said.
At the Durham meeting, Dr. Kniker reported findings from the first phase of a two-part case-control study of 28 individuals with autism, living in full-time residential homes. The study team collected baseline data in January this year, and assessed dietary and medical histories, urine peptide profiles, Autism Treatment Evaluation Checklist, and behavioral information. During the first phase of the 3-month intervention, milk and dairy products, food colorings, grains, caffeine, and other food components were eliminated from the diet, and the same data were collected again.
Dr. Kniker explained that 10 of 28 participants changed dramatically. "Five of these ten improved in many of the parameters examined, but to our surprise, the other five deteriorated." He added that "the deterioration experienced by the five individuals may be explained if the removal of these foods unmasked negative effects of other foods that they may not ordinarily consume."
The second phase of the study was initiated April 2. "We have now removed a different set of foods, including soy products, peanuts, buckwheat and grape from their diets, and will assess whether those who improved previously improve further; whether those where diet had no effects improve; and whether individuals who deteriorated in the first part of the trial get better," Dr. Kniker said.
"Our study was extremely tight and very dependable as residents' diets were completely controlled, and they were only home on weekends, when they had strict dietary instructions," he added.
In an interview with Reuters Health, co-researcher Dr. Alonzo Andrews, director of the Autistic Treatment Center, said: "We also monitored disruptive behavior, communication skills and other psychological parameters. We saw trends in four individuals towards improved behavior, and a decline in behavior in another four."
He added that "in two responders, we noted improved cognition and sociability. Staff also said these individuals were more alert and retentive, although there was an associated increase in behavioral problems. We would conclude, however, that they had improved overall."
Dr. Kniker observed that "autism is becoming a world-wide pandemic. The incidence has risen from 1 in 5000 to 10,000 individuals in the 70s and 80s to 1 in 500; newer data even suggest an incidence of 1 in 100 to 200."
"It is clearly not a congenital developmental disorder of the brain. Environmental factors must be involved, and foodstuffs, vaccination and pathogens have all been suggested to play a role, although genetic background is likely to have some influence."
He concluded by saying that whilst far more research still needs to be conducted, he hopes that results from the second half of their study, due in May, will yield further clues to the causes of and treatment for autism.

Pressure to Smoke Varies by Ethnicity
A new study shows that white teenagers are more likely to take up smoking because of peer pressure, Reuters reported June 11. On the other hand, the report found that Hispanic and African-American adolescents may be more readily influenced by family members or societal standards. "Most teens smoke because their friends are doing it," said Dr. Jennifer B. Unger of the University of Southern California School of Medicine. "However, teens from more collectivistic, family-oriented cultures may be less influenced by their friends' behavior, compared with whites."
For the study, Unger and colleagues interviewed 5, 000 California 8th-graders. The researchers found that 70 percent of Hispanics and multiethnic adolescents were at risk of smoking, compared to 60 percent of whites and less than 50 percent of Asian-Americans. Hispanics and multiethnic youths were also the most likely to be current smokers; African-American youth were the least likely to be active smokers.
Unger said the study' findings could be beneficial for designing smoking cessation and prevention programs for adolescents. "These results support the hypothesis that peer influences on adolescent smoking vary by ethnicity," the researchers wrote. "Our society is becoming more and more multicultural. We can't continue to design our health-promotion programs with just U.S.-born whites in mind. We need to consider the cultural values of multiple cultures."
The report is published in the June issue of Nicotine and Tobacco Research.

Brain Differences Seen in Children from Alcohol-Dependent Families
A new study shows that children from families with several generations of alcohol dependence exhibit differences in their brain when compared to children without a family history of alcoholism, Reuters reported June 8. For the study, 17 teenagers considered high risk for alcohol dependence because of a strong family history of alcoholism underwent MRI scans. The results were compared with MRIs from 17 teens without a family history of alcoholism.
The study found that teens with a family history of alcoholism had a smaller amygdala, the right side of an area of the brain that controls basic emotions. "When we looked at some of the children who hadn't had any drugs or alcohol to speak of, the same pattern of smaller right amygdala volume was seen," said Dr. Shirley Y. Hill of the University of Pittsburgh. "Why the right amygdala? We are not sure."
The amygdala is part of a "reward circuit" within the brain, which is associated with some addictive behaviors. Hill explained that a smaller amygdala could indicate a developmental delay that affects this circuit.
"The paper is the first demonstration that a brain structure that is part of a circuit that is involved in both emotion and cognition may be smaller in adolescents from families with a high loading of alcohol dependence before they drink," said Hill.
The study's findings are published in the June issue of the journal Biological Psychiatry.

Characteristics of Adolescents' Sexual Partners and Their Association with Use Of Condoms and Other Contraceptive Methods
Context: While a number of studies have examined the association between individuals' characteristics and their contraceptive use, few studies have examined the influence of partners' characteristics on individuals' contraceptive use.
Methods: Using nationally representative data from the National Longitudinal Study of Adolescent Health, multiple logistic analyses were conducted to identify associations between the demographic characteristics of adolescents' heterosexual partners and adolescents' use of condoms or other contraceptive methods.
Results: The partners of white and black adolescents were likely to be similar to them, while the partners of Latino adolescents and of adolescents of "other" race or ethnicity were more likely to be of a different racial or ethnic group. Differences in age between adolescents and their partners were notable in all racial and ethnic groups. As adolescents age, the characteristics of their partners become more heterogeneous. The less similar adolescents and their partners are to one another--whether because of a difference in age, grade or school--the less likely adolescents are to use condoms and other contraceptive methods.
Conclusions: Many adolescents have relationships with partners whose characteristics differ from theirs and with whom they are less likely to use condoms or other contraceptive methods. This behavior is more common as adolescents grow older. To provide appropriate counseling, sexuality educators and family planning providers need to consider the ways in which adolescents' relationships change as they age and discuss with them the dynamics of relationships involving partners who differ in age or other characteristics.
Family Planning Perspectives, 2001, 33(3):100-105 & 132

Physical Activity Increases Bone Density in Children
Physical activity increases bone density in children as young as 4 years of age, according to a report in the June issue of Pediatrics.
Dr. Kathleen F. Janz and colleagues from the University of Iowa in Iowa City asked 368 preschool children, aged 4 to 6 years, to wear an accelerometer, which measures movement, for 4 days. The researchers also made dual-energy radiograph absorptiometry measurements of the children's bone mineral content and bone mineral density (BMD).
Accelerometry data and parent reports of physical activity were consistently and positively associated with bone mineral content and BMD in both boys and girls, the authors report, even after adjustment for age and body size. Children in the highest quartile of activity had 5% greater hip BMD than did children in the lowest quartile.
In logistic regression analyses, physical activity was the most powerful predictor of most measures of bone mineral content and BMD, the researchers note. Increased television viewing, in contrast, predicted lower bone mineral content and lower BMD, particularly in girls.
"Physicians should feel more confident of the worthiness of their efforts to communicate with patients the need to do everything possible to help children optimize bone development, so that later in life their children are better able to preserve the skeleton," Dr. Janz told Reuters Health. "In addition to adequate calcium, physicians need to counsel parents about the need for vigorous bone-building activity such as jumping, running, tumbling."
"Since peak bone mass is a major determinant of osteoporosis in later years, and peak bone mass is largely determined by [age] 20 years, it only makes sense that healthcare providers should be familiar with the determinants of bone mass, exercise being one of them," co-author Dr. Marcia C. Willing said in a separate interview. "Prevention is one of the most important components to pediatric medicine, and every pediatrician and family practitioner should step up to the plate and try to prevent this adult-onset condition."
Pediatrics 2001;107:1387-1393.

Study Found Nearly 1 In 5 Teenage Girls Have an Undiagnosed STD 
Undiagnosed sexually transmitted diseases (STDs) were found in 18% of teenage girls who provided vaginal samples they collected themselves during a 2-year study. The findings were reported in the June issue of Sexually Transmitted Diseases.
"The study is significant because it shows that a self-testing option can be very valuable in detecting previously undiagnosed STDs in an adolescent population," said primary study author Harold Wiesenfeld, MD, an assistant professor of obstetrics, gynecology and reproductive sciences at the University of Pittsburgh School of Medicine, Pennsylvania. He is also a physician in the departments of gynecology and infectious diseases at Magee-Womens Hospital of UPMC Health System.
"Nearly 13 percent of women had never previously had a gynecological exam tested positive for an STD, and 51 percent of infected students would not have pursued STD testing by traditional gynecological examination," wrote Dr. Wiesenfeld.
Two hundred and twenty-eight female students aged 15 to 19 years took part in the study through school-based health clinics at 2 Pittsburgh-area high schools in 1997 and 1998. Students were instructed on how to collect vaginal swabs, which were then tested in labs at the Magee-Womens Research Institute. Disease rates identified were 10% for trichomoniasis; 8%, chlamydia; and 2% tested positive for gonorrhea. Trichomoniasis can cause painful inflammation, itching, and vaginal discharge. A bacterial infection, gonorrhea is one of the most common infectious diseases in the world.
"Self-collection of vaginal swabs was almost uniformly reported as easy to perform, and preferable to gynecological examination," the authors wrote. "Nearly all stated that they would undergo testing at frequent intervals if self-testing was available."
"Symptoms of some sexually transmitted diseases are often unclear, or even absent," noted senior study author Richard Sweet, MD, the Lawrence Milton McCall professor and chairman of the university's department of obstetrics, gynecology and reproductive sciences. "In fact, most of these girls came to the health clinics for other reasons entirely, like a sports injury or a headache."
STDs include a variety of infections such as chlamydia, gonorrhea, syphilis, trichomoniasis and genital herpes. Chlamydia is the most common sexually transmitted disease in the United States, affecting an estimated 13 percent of women.
Untreated STDs can result in loss of fertility, and, in some cases, have extreme long-term consequences including heart valve inflammation and arthritis. Pelvic inflammatory disease, which is often a complication of infection, is a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. Trichomoniasis has been associated with pregnancy complications such as premature fetal membrane rupture. In addition, the link between STD infection and HIV transmission is becoming ever more apparent.
Major funding for the study was provided by the Jewish Healthcare Foundation of Pittsburgh.
Sex Transm Dis. 2001;28(6):321-325
Full report

'Hot Spot' on Brain Responds to Drugs
Researchers have discovered that a "hot spot" on the brain responds to drugs such as amphetamines and cocaine, Reuters reported May 24. In examining the nucleus accumbens, located at the base of the forebrain, researchers found that this area is the key to impulsive behavior and is involved in the choice between instant gratification and delayed reward.
"We have shown that damage or dysfunction of the nucleus accumbens can cause, without a doubt, impulsive choice," said study author Rudolf Cardinal of the Department of Experimental Psychology at Britain's University of Cambridge.
For the study, researchers trained rats to choose between a small, immediate reward and a larger, delayed reward. In instances where the nucleus accumbens were damaged, researchers found that the rats were more likely to choose instant gratification rather than the larger reward delivered after a delay.
"We already knew that there was a correlation between abnormalities in the nucleus accumbens and impulsive behavior," Cardinal said. "Now we have clear evidence that such abnormalities can cause this behavior."
Cardinal said that the finding's could help in the treatment and understanding of addiction. He added that further research is needed to determine why the rats with nucleus accumbens lesions became impulsive.
"That's one question about the underlying psychology," Cardinal said. "Do you make your impulsive choices in the full knowledge of what you are getting yourself into? Or do you lack insight into the consequences?"
The study's findings were published May 24 in the online version of the journal Science.

Few Medical Students Learn About Addiction
Medical education on addictions has improved in the 25 years since the founding of the Association for Medical Education and Research in Substance Abuse, but it's still relatively rare for medical students to get comprehensive training on identifying and treating addictive disorders.
Over the years, AMERSA has advocated for improved physician training, and agencies like the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have provided funding for medical-school curriculum development and faculty education. Results of these efforts have included the development of guidelines for teaching about addiction in the fields of internal medicine, pediatrics, psychiatry, family medicine, emergency medicine, and obstetrics/gynecology, and a significant expansion of elective courses on addictions offered at major medical schools.
"But few require substance abuse in their [core] curriculum," noted Bud Isaacson, M.D., vice chairman of the Department of General Internal Medicine at the Cleveland Clinic, who spoke at the recent annual meeting of the American Society of Addiction Medicine in Los Angeles, Calif.
In a survey of medical-school directors published in the November 2000 edition of the Journal of Studies on Alcohol, Isaacson found that while 95 percent of schools for psychiatry required addiction classroom training, just 75 percent of schools for family physicians did so. And even fewer required residents to do a rotation at an addiction-treatment facility.
In spite of the pervasive presence of addiction problems in emergency rooms and fetal alcohol syndrome's status as the nation's leading cause of preventable birth defects, Isaacson's survey found that these and other areas of medicine gave especially short shrift to addiction training. Only 55 percent of curricula for emergency medicine included any course hours for addictive disorders; for internal medicine, 51 percent; for osteopathy, 41 percent; for OB/GYN, 39 percent; and for pediatrics, 31.8 percent.
Even course requirements were no guarantee of an immersive experience: Isaacson pointed out that programs for emergency physicians and OB/GYNs included an average of only 3 hours of addiction training, and even psychiatry schools required only 8 hours of training on addictions. "The number of hours was really quite small," Isaacson noted.
Given such limitations, it's not surprising that students rarely learned more than simple screening techniques and information about detoxification, and heard little about treatment follow-up or brief interventions. Such programs stand in sharp contrast to models like the Brody School of Medicine at East Carolina University in Greenville, N.C., where students not only receive extensive classroom training, but must attend local A.A. meetings, which counts as 15 percent of their grade. Graduates have shown a "dramatic improvement" in their assessment skills, confidence in making referrals to treatment and self-help groups, and overcoming preconceptions of addiction as a moral weakness or issue of willpower, said Jerome Schulz, M.D., a clinical professor at the school.
Medical-school directors said that lack of time, faculty experience, institutional support, and training sites were to blame for the dearth of addiction training. "Overall, psychiatry and family medicine are the most involved, but we have a long way to go," said Isaacson.
To address the problem, Isaacson and other advocates for medical training look to the Health Resources and Services Administration's Project Mainstream, intended to bring addiction training into the mainstream of medicine. Physicians also need to put pressure on residency review committees to enforce training requirements for addiction, said Isaacson.
Few Medical Students Learn About Addiction. Feature article by Bob Curley for Join Together Online (www.jointogether.org), June 1, 2001.

Gay, Bisexual Teens at Risk for Violence
A new national survey suggests that homosexual and bisexual adolescents run a significantly higher risk of witnessing, experiencing violence than do their heterosexual peers.
The report backs up earlier, smaller studies linking gay or lesbian sexual orientation to an increased risk of violence. It is also the first to suggest that lesbian, gay, and bisexual (LGB) teens may be more likely than straight teens to perpetrate violence.
Researchers in part blamed a lack of safe meeting places where homosexual and bisexual teens can socialize, a situation they say forces the teens to frequent adult bars and clubs that may be dangerous.
"It is likely that in seeking LGB communities, LGB youths put themselves in settings where they are more likely to witness violence," the investigators report in the June issue of the American Journal of Public Health, the Journal of the American Public Health Association.
The study used a nationwide questionnaire of about 10,600 male and female students in grades 7 through 12. About 1% of the total (108 students) told researchers that they were attracted only to the same sex, while 524, about 5% said that they had attraction for both sexes.
Overall, one third of adolescents reported having been in physical fights, though homosexual and bisexual teens were no more likely to report fighting than heterosexual teens.
But the survey showed that homosexual adolescents were nearly twice as likely to reveal a history of violent attacks and witnessing violence. They were also twice as likely as straight adolescents to report being involved in violence requiring medical attention, the report indicates.
Meanwhile, gay and lesbian teens were nearly 2.5 times more likely to report that they had perpetrated violence against someone else. Bisexual adolescents reported no increased levels of perpetrating violence but were more likely than heterosexual kids to report witnessing violence or being jumped and were 1.5 times more likely to report needing medical attention after a violent episode.
Past studies have suggested that as many 44% of gay youths had been threatened with violence. The new findings suggesting that lesbian and gay teens may also be more violent than their heterosexual peers could indicate that many gay teens are taking a posture of self-defense against perceived threats, said Anne K. Driscoll, researcher at the University of California at Davis.
"It does seem that the kids that feel threatened by other kids are the ones more likely to be in a fight or be violent themselves," Driscoll told Reuters Health. She cautioned that researchers do not yet have the data to definitively explain the phenomenon.
The survey did not ask teens whether they were open with others about their sexual orientation, a factor the researchers acknowledge could result in aggressive reactions from other people.
SOURCE: American Journal of Public Health 2001;91

Single Exposure to Cocaine May 'Prime' the Brain for Addiction 
In mice, a single in vivo exposure to cocaine induces a week-long response that seems to make the brain more responsive to subsequent exposure, according to a report in the May 31st issue of Nature.
"The study shows that the capacity for strengthening connections between nerve cells...can be usurped by drugs of abuse," Dr. Antonello Bonci from the University of California at San Francisco said in a journal statement. "The single exposure appears to hijack the brain's normal molecular mechanisms of memory formation for around a week."
Dr. Bonci and colleagues exposed mouse cells from the ventral tegmental area, a part of the brain that is central to addition, to cocaine on a single occasion. This exposure "induced a long-term potentiation of alpha-amino-3-hydroxy-5-methyl-isoxazole propionic acid (AMPA)-receptor-mediated currents at excitatory synapses onto dopamine cells in the VTA," the researchers report.
AMPA is involved in learning and memory, they note, two cognitive tasks that involve activation of neurons in the dopamine-rich ventral tegmental area.
"When you learn something, you might expect to see a change in very few synaptic connections," coauthor Dr. Mark A. Ungless said in the journal statement. "What's so amazing is that nearly all dopamine neurons are affected by this single cocaine exposure. This kind of response is extremely rare, and would have a profound effect throughout the brain, particularly other areas involved in addiction."
The potentiation of AMPA lasted for 5 days and was not present after 10 days. The effect was blocked when N-methyl-D-aspartate receptor antagonist was given along with cocaine.
The findings may lead to new methods of treating drug addiction, the investigators suggest. "The question is how to develop drugs that interfere with these cocaine-induced changes but not with normal memory formation. This is something we plan to explore," Dr. Bonci commented.
Source: Nature 2001;411:583-587.

Evidence Accumulating For Biological Basis of Eating Disorders 
Genetic research and brain imaging studies are uncovering a biological basis for eating disorders, according to Dr. Walter H. Kaye of the University of Pittsburgh, who spoke Tuesday at the 154th annual meeting of the American Psychiatric Association.
"Eating disorders have been thought to be psychosocial for some time, but we're learning that a powerful underlying biology also contributes," he told Reuters Health. "The latest studies of people after recovery from bulimia show that there are some differences between these patients and healthy volunteers."
Several previous studies have suggested that the tendency to develop such a condition is transmitted genetically. For example, Dr. Kaye noted that people with eating disorders may have a serotonin disturbance that is trait-related. He and colleagues are involved in an ongoing study attempting to identify genetic factors that play a role in the etiology of anorexia nervosa and bulimia nervosa.
"There are areas of the genome that may be candidates, but no individual genes have been identified yet," Dr. Kaye said. "There is probably not one single gene responsible for these conditions, but there is more likely a combination of genes."
In a presentation here, he reported that positron emission tomography results suggest that serotonin receptor activity in recovering bulimics differs from that of healthy volunteers. Differences were found in the medial orbital frontal cortex, which is involved with mood and impulse control. A similar study of recovering anorexics is under way.
"We hope that a better understanding of brain mechanisms will lead to better treatment," Dr. Kaye told Reuters Health. "There are probably pathways in the brain that regulate mood and impulse control. Conditions such as obsessive-compulsive disorder and the eating disorders probably involve those pathways, but in different ways."
American Psychiatric Association

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